Combination therapies for treatment of cancer

ABSTRACT

Combination therapies for treatment of cancer are provided. The disclosed methods comprise administration of a cyclin-dependent kinase inhibitor and a DNA methyltransferase inhibitor to a mammal in need thereof.

BACKGROUND Technical Field

The present invention is generally directed to methods for treatment of cancer by administration of a cyclin-dependent kinase inhibitor and a DNA methyltransferase inhibitor.

Description of the Related Art

Myelodysplastic Syndrome (MDS) is a diverse group of bone marrow disorders characterized by the inability to produce healthy numbers of blood cells. Frequently (around 30%) MDS progresses to acute myelogenous leukemia (AML), which remains largely an incurable condition with relatively poor survival rates. One treatment option for MDS is the hypomethylating agents azacitidine and deoxyazacitidine (deitabine), which act by 2 principle mechanisms: 1) inhibiting DNA methyltransferases, which leads to the activation of key tumor suppressor genes; and 2) directly damaging DNA following incorporation in replicating DNA strands. The second of these mechanisms activates the programmed cell-death pathway (apoptosis), and this pathway has been shown to depend somewhat on the expression levels of key apoptosis regulatory proteins, including MCL-1, an anti-apoptotic member of the BH3 family of apoptotic regulating proteins.

Cyclin-dependent kinases (CDKs) are important regulators that control the timing and coordination of the cell cycle. CDKs form reversible complexes with their obligate cyclin partners to control transition through key junctures in the cell cycle. In addition to regulating cell cycle progression, some CDK family members also play an active role in transcription, for example CDK7 and CDK9. In particular, CDK9 directly phosphorylates RNA Polymerase II and contributes towards productive transcription. Agents which inhibit CDK9 have been shown to inhibit the expression of MCL-1, an important protein in the apoptosis pathway activated by DNA methyltransferase inhibitors. One such CDK inhibitor is alvocidib, which is a potent and selective inhibitor of the CDKs (e.g., CDK-9) and has antitumor activity against various tumor cells lines. Alvocidib is also known to rapidly decrease expression levels of MCL-1.

To date, them have been no reports of combinations of DNA methyltransferase inhibitors and cyclin-dependent kinase inhibitors for treatment of cancers, such as MDS and/or AML. While progress has been made, there remains a need in the art for improved combination therapies for treatment of various cancers. The present invention fulfills this need and provides related advantages.

BRIEF SUMMARY

In brief, embodiments of the present invention provide methods for treatment of cancer comprising administration of two different therapeutic agents. In one embodiment the disclosure provides a method for treating cancer in a mammal in need thereof, the method comprising administering to the mammal an effective amount of the following therapeutic agents:

-   -   i) a cyclin-dependent kinase inhibitor, and     -   ii) a DNA methyltransferase inhibitor.

Kits comprising a cyclin-dependent kinase inhibitor, a DNA methyltransferase inhibitor, and instructions for administering the cyclin-dependent kinase inhibitor and the DNA methyltransferase inhibitor to a mammal in need of treatment for cancer, as well as pharmaceutical compositions useful in the disclosed methods, are also provided.

These and other aspects of the invention will be apparent upon reference to the following detailed description. To this end, various references are sot forth heroin which describe in more detail certain background information, procedures, compounds and/or compositions, and are each hereby incorporated by reference in their entirety.

BRIEF DESCRIPTION OF THE DRAWINGS

In the figures, identical reference numbers identify similar elements. The sizes and relative positions of elements in the figures are not necessarily drawn to scale and some of these elements are arbitrarily enlarged and positioned to improve figure legibility. Further, the particular shapes of the elements as drawn are not intended to convey any information regarding the actual shape of the particular elements, and have been solely selected for ease of recognition in the figures.

FIG. 1A provides relative expression levels of MCL-1 compared to β-actin in MV 4-11 cells across a range of alvocidib doses.

FIG. 1B is a gel showing relative expression levels of MCL-1 compared to A-actin in MV 4-11 cells across a range of time points.

FIG. 2 is a graph of cell showing the synergistic effect of combining alvocidib with azacitidine to inhibit MV 4-11 cell growth.

FIG. 3 present caspase 3/7 activity compared with concentration on a logarithmic scale for combinations of alvocidib with azacitidine to induce apoptosis in MV 4-11 cells.

FIGS. 4A-D are bar graphs providing data for treatment of MV 4-11 cells with alvocidib or azacitidine alone, or in combination, at various concentrations of azacitidine.

FIGS. 5A and 5B present data from combination treatment of alvocidib and decitabine in MV4-11 cells.

DETAILED DESCRIPTION

In the following description, certain specific details are set forth in order to provide a thorough understanding of various embodiments of the invention. However, one skilled in the art will understand that the invention may be practiced without these details.

Unless the context requires otherwise, throughout the present specification and claims, the word “comprise” and variations thereof, such as, “comprises” and “comprising” are to be construed in an open, inclusive sense, that is, as “including, but not limited to”.

Reference throughout this specification to “one embodiment” or “an embodiment” means that a particular feature, structure or characteristic described in connection with the embodiment is included in at least one embodiment of the present invention. Thus, the appearances of the phrases “in one embodiment” or “in an embodiment” in various places throughout this specification are not necessarily all referring to the same embodiment. Furthermore, the particular features or characteristics may be combined in any suitable manner in one or more embodiments.

A “DNA methyltransferase inhibitor” is an agent having dual activity as an inhibitor of DNA methyltransferase (i.e., a hypomethylating agent) and activity as a DNA-damaging agent. Exemplary DNA methyltransferase inhibitors are incorporated into DNA (e.g., DNA in a cancer cell), thereby inhibiting DNA methyltransferase and leading to DNA damage and apoptosis. Exemplary DNA methyltransferase inhibitors include nucleoside analogues, such as azanucleosides.

A “cyclin-dependent kinase inhibitor” is an agent which inhibits the activity of cyclin dependent kinases (CDKs), including CDK1, CDK2, CDK3, CDK4, CDK5, CDK6, CDK7, CDK8, CDK9 and CDK11. Exemplary CDK inhibitors inhibit the expression of MCL-1. Exemplary CDK inhibitors include, but are not limited to, alvocidib, dinaciclib, olomoucine, roscovitine, purvalanol, paullones, palbociclib, thio/oxoflavopiridols, oxindoles, aminothiazoles, benzocarbazoles, pyrimidines and seliciclib.

“Alvocidib” (also known as “Flavopiridol”) is a synthetic flavone having the following structure:

“Azanucleosides” are analogues of natural occurring nucleosides, wherein at least one carbon atom has been replaced with a nitrogen atom. Exemplary azanucleosides include azacitidine and decitabine, which have the following structures, respectively:

“Mammal” includes humans and both domestic animals such as laboratory animals and household pets (e.g., cats, dogs, swine, cattle, sheep, goats, horses, rabbits), and non-domestic animals such as wildlife and the like.

A “pharmaceutical composition” refers to a formulation of a compound of the invention and a medium generally accepted in the art for the delivery of the biologically active compound to mammals, e.g., humans. Such a medium includes all pharmaceutically acceptable carriers, diluents or excipients therefor.

“Effective amount” or “therapeutically effective amount” refers to that amount of a compound of the invention which, when administered to a mammal, preferably a human, is sufficient to effect treatment, as defined below, of a cancer in the mammal, preferably a human. The amount of a compound of the invention which constitutes a “therapeutically effective amount” will vary depending on the compound, the condition and its severity, the manner of administration, and the age of the mammal to be treated, but can be determined routinely by one of ordinary skill in the art having regard to his own knowledge and to this disclosure.

“Treating” or “treatment” as used herein covers the treatment of the disease or condition of interest in a mammal, preferably a human, having cancer, disease, or condition of interest, and includes:

-   -   (i) preventing the cancer, disease, or condition from occurring         in a mammal, in particular, when such mammal is predisposed to         the condition but has not yet been diagnosed as having it;     -   (ii) inhibiting the cancer, disease, or condition, i.e.,         arresting its development;     -   (iii) relieving the cancer, disease, or condition, i.e., causing         regression of the disease or condition; or     -   (iv) relieving the symptoms resulting from the cancer, disease,         or condition, i.e., relieving pain without addressing the         underlying disease or condition. As used hemin, the terms         “disease” and “condition” may be used interchangeably or may be         different in that the particular malady or condition may not         have a known causative agent (so that etiology has not yet been         worked out) and it is therefore not yet recognized as a disease         but only as an undesirable condition or syndrome, wherein a more         or less specific set of symptoms have been identified by         clinicians.

I. Method

In certain embodiments, the methods are useful for treating cancer cells and/or for preventing, treating, or ameliorating a cancer and/or symptoms thereof, in a mammal, preferably a human. Accordingly, in one embodiment the disclosure provides a method for treating a cancer in a mammal in need thereof, the method comprising administering to the mammal a therapeutically effective amount of the following therapeutic agents:

-   -   i) a cyclin-dependent kinase inhibitor, and     -   ii) a DNA methyltransferase inhibitor.

In certain embodiments, the cyclin-dependent kinase inhibitor inhibits cyclin-dependent kinase (Cdk) proteins, such as Cdk4, Cdk6, Cdk7, Cdk8, Cdk9, Cdk10 and/or Cdk11. In some embodiments, the cyclin-dependent kinase inhibitor inhibits Cdk7, Cdk9 or both. In other embodiments, the cyclin dependent kinase inhibitor inhibits expression of MCL-1. In some embodiments, the cyclin-dependent kinase inhibitor is alvocidib or dinaciclib or a pharmaceutically acceptable salt thereof. For example, in some more specific embodiments the cyclin-dependent kinase inhibitor is alvocidib or a pharmaceutically acceptable salt thereof. In some other specific embodiments the cyclin-dependent kinase inhibitor is dinaciclib or a pharmaceutically acceptable salt thereof.

In some embodiments, the DNA methyltransferase is capable of being incorporated into RNA and/or DNA. In other embodiments, the DNA methyltransferase inhibitor activates apoptosis due to DNA damage. In still different embodiments, the DNA methyltransferase inhibitor is a nucleoside analogue. In more embodiments, the DNA methyltransferase inhibitor is an azanucleoside, such as azacitidine or decitabine a pharmaceutically acceptable salt thereof. In some more specific embodiments, the DNA methyltransferase inhibitor is azacitidine or a pharmaceutically acceptable salt thereof. In some other embodiments, the DNA methyltransferase inhibitor is decitabine or a pharmaceutically acceptable salt thereof.

In further embodiments of the foregoing, the cyclin-dependent kinase inhibitor is alvocidib, or a pharmaceutically acceptable salt thereof, and the DNA methyltransferase inhibitor is azacitidine or a pharmaceutically acceptable salt thereof. In other different embodiments, the cyclin-dependent kinase inhibitor is alvocidib, or a pharmaceutically acceptable salt thereof, and the DNA methyltransferase inhibitor is decitabine or a pharmaceutically acceptable salt thereof.

The cyclin-dependent kinase inhibitor and the DNA methyltransferase inhibitor can be co-administered or administered sequentially. For example, in some embodiments the cyclin-dependent kinase inhibitor is administered and after a sufficient period of time the DNA methyltransferase inhibitor is administered. In some other embodiments the DNA methyltransferase inhibitor is administered and after a sufficient period of time the cyclin-dependent kinase inhibitor is administered. One of ordinary skill in the art can derive an appropriate dosing schedule based on common techniques and knowledge.

In some embodiments, the cyclin-dependent kinase inhibitor is administered to the mammal prior to administration of the DNA methyltransferase inhibitor. For example in some embodiments, the DNA methyltransferase inhibitor is administered within about 24 to 48 hours after administration of the cyclin-dependent kinase inhibitor. In some other embodiments, the DNA methyltransferase inhibitor is administered to the mammal prior to administration of the cyclin-dependent kinase inhibitor.

A wide variety of cancers, including solid tumors and leukemias (e.g., acute myeloid leukemia) are amenable to the methods disclosed herein. Types of cancer that may be treated in various embodiments include, but are not limited to: adenocarcinoma of the breast, prostate, and colon; all forms of bronchogenic carcinoma of the lung; myeloid; melanoma; hepatoma; neuroblastoma; papilloma; apudoma; choristoma; branchioma; malignant carcinoid syndrome; carcinoid heart disease; and carcinoma (e.g., Walker, basal cell, basosquamous, Brown-Pearce, ductal, Ehrlich tumor, Krebs 2, merkel cell, mucinous, non-small call lung, oat cell, papillary, scirrhous, bronchiolar, bronchogenic, squamous cell, and transitional cell). Additional types of cancers that may be treated include: histiocytic disorders; leukemia; histiocytosis malignant; Hodgkin's disease; immunoproliferative small; non-Hodgkin's lymphoma; plasmacytoma; reticuloendotheliosis; melanoma; chondroblastoma; chondroma; chondrosarcoma; fibroma; fibrosarcoma; giant cell tumors; histiocytoma; lipoma; liposarcoma; mesothelioma; myxoma; myxosarcoma; osteoma; osteosaroma; chordoma; craniopharyngioma; dysgerminome; hamartoma; mesenchymoma; mesonephroma; myosarcoma; ameloblastoma; cementoma; odontoma; teratoma; thymoma; trophoblatic tumor. Further, the following types of cancers are also contemplated as amenable to treatment: adenoma; cholangioma; cholesteatoma; cyclindroma; cystadenocarcinoma; cystadenoma; granulosa cell tumor; gynandroblastoma; hepatoma; hidradenoma; islet cell tumor; Leydig cell tumor; papilloma; sertoli cell tumor; theca cell tumor; leimyoma; leiomyoarcoma; myoblastoma; myomma; myosarcoma; rhabdomyoma; rhabdomyosarcoma; ependymoma; ganglioneuroma; glioma; medulloblastoma; meningioma; neurilemmoma; neuroblastoma; neuroepithelioma; neurofbroma; neuroma; paraganglioma; paraganglioma nonchromaffin. The types of cancers that may be treated also include, but am not limited to, angiokeratoma; angiolymphoid hyperplasia with eosinophilia; angioma sclerosing; angiomatosis; glomangioma; hemangioendothelioma; hemangioma; hemangiopericytoma; hemangiosarcoma; lymphangloma; lymphangiomyoma; lymphangiosarcoma; pinealoma; carcinosarcoma; chondroarcoma; cystosarcoma phyllodes; fibrosarcoma; hemangosarcoma; leiomyosarcoma; leukosarcoma; liposarcoma; lymphangiosarcoma; myoaroma; myxosarcoma; ovarian carcinoma; rhabdomyosarcoma; sarcoma; neoplasms; nerofibromatosis; and cervical dysplasia.

In certain more specific embodiments, the cancer is a hematologic cancer. For example, in some embodiments the hematologic cancer is selected from acute myelogenous leukemia (AML), multiple myeloma, follicular lymphoma, acute lymphoblastic leukemia (ALL), chronic lymphocytic leukemia (CLL) and non-Hodgkin's lymphoma. In other embodiments, the hematological cancer is acute myelogenous leukemia (AML). In some more embodiments, the hematologic cancer is myelodysplastic syndrome (MDS).

II. Kits and Pharmaceutical Compositions

Other embodiments are directed to kits useful for implementation of the disclosed methods. For example, in some embodiments is provided a kit comprising a cyclin-dependent kinase inhibitor, a DNA methyltransferase inhibitor, and instructions for administering the cyclin-dependent kinase inhibitor and the DNA methyltransferase inhibitor to a mammal in need of treatment for cancer. In some embodiments, the cyclin-dependent kinase inhibitor present in the kit is as defined in any one of the foregoing embodiments. In other embodiments, the DNA methyltransferase inhibitor which is part of the kit is as defined in any of the foregoing embodiments. In still more embodiments, the cancer treatable with the kits is as defined in any one of the foregoing embodiments.

In other embodiments pharmaceutical compositions are provided. For example, in some embodiments the pharmaceutical composition comprises a pharmaceutically acceptable carrier or excipient and the following therapeutic agents:

-   -   i) a cyclin-dependent kinase inhibitor, and     -   ii) a DNA methyltransferase inhibitor.

The therapeutic agents present in the pharmaceutical compositions may be any of those described herein or known in the art. In some embodiments, the composition comprises alvocidib. In some other embodiments, the composition comprises azacitidine. In some embodiments, the composition comprises decitabine. In some other embodiments the pharmaceutical composition comprises a pharmaceutically acceptable carrier or excipient, alvocidib and azacitidine. In different embodiments the pharmaceutical composition comprises a pharmaceutically acceptable carrier or excipient, alvocidib and decitabine.

In some embodiments, the pharmaceutical composition is formulated for oral administration. In other embodiments, the pharmaceutical composition is formulated for injection.

Suitable routes of administration include, but are not limited to, oral, intravenous, rectal, aerosol, parenteral, ophthalmic, pulmonary, transmucosal, transdermal, vaginal, otic, nasal, and topical administration. In addition, by way of example only, parenteral delivery includes intramuscular, subcutaneous, intravenous, intramedullary injections, as well as intrathecal, direct intraventricular, intraperitoneal, intralymphatic, and Intranasal Injections.

In certain embodiments, one or more of the compounds as described herein (i.e., a cyclin dependent kinase inhibitor and/or a DNA methyltransferase inhibitor, referred to herein as “the compounds”) are administered in a local rather than systemic manner, for example, via injection of the compound directly into an organ, often in a depot preparation or sustained release formulation. In specific embodiments, long acting formulations are administered by implantation (for example subcutaneously or intramuscularly) or by intramuscular injection. Furthermore, in other embodiments, the one or more of the compounds are delivered in a targeted drug delivery system, for example, in a liposome coated with organ-specific antibody. In such embodiments, the liposomes are targeted to and taken up selectively by the organ. In yet other embodiments, one or more of the compounds are provided in the form of a rapid release formulation, in the form of an extended release formulation, or in the form of an intermediate release formulation. In yet other embodiments, one or more of the compounds are administered topically.

The compounds are effective over a wide dosage range. For example, in the treatment of adult humans, dosages from 0.01 to 1000 mg, from 0.5 to 100 mg, from 1 to 50 mg per day, and from 5 to 40 mg per day are examples of dosages that are used in some embodiments. An exemplary dosage is 10 to 30 mg per day. The exact dosage will depend upon the route of administration, the form in which the compound is administered, the subject to be treated, the body weight of the subject to be treated, and the preference and experience of the attending physician.

In some embodiments, one or more of the compounds are administered in a single dose. Typically, such administration will be by injection, e.g., intravenous injection, in order to introduce the agent quickly. However, other routes are used as appropriate. A single dose of the compounds may also be used for treatment of an acute condition.

In some embodiments, one or more of the compounds are administered in multiple doses. In some embodiments, dosing is about once, twice, three times, four times, five times, six times, or more than six times per day. In other embodiments, dosing is about once a month, once every two weeks, once a week, or once every other day. In another embodiment the compounds are administered together about once per day to about 6 times per day. In another embodiment the administration of the compounds continues for less than about 7 days. In yet another embodiment the administration continues for more than about 6, 10, 14, 28 days, two months, six months, or one year. In some cases, continuous dosing is achieved and maintained as long as necessary.

Administration of the compounds may continue as long as necessary. In some embodiments, the compounds are administered for more than 1, 2, 3, 4, 5, 6, 7, 14, or 28 days. In some embodiments, the compounds are administered for less than 28, 14, 7, 6, 5, 4, 3, 2, or 1 day. In some embodiments, the compounds are administered chronically on an ongoing basis, e.g., for the treatment of chronic effects.

In some embodiments, the compounds are administered in dosages. Due to intersubject variability in compound pharmacokinetics, individualization of dosing regimen is provided in certain embodiments. Dosing for the compounds may be found by routine experimentation in light of the instant disclosure and/or can be derived by one of ordinary skill in the art.

In some embodiments, the compounds are formulated into pharmaceutical compositions. In specific embodiments, pharmaceutical compositions are formulated in a conventional manner using one or more physiologically acceptable carriers comprising excipients and auxiliaries which facilitate processing of the active compounds into preparations which can be used pharmaceutically. Proper formulation is dependent upon the route of administration chosen. Any pharmaceutically acceptable techniques, carriers, and excipients are used as suitable to formulate the pharmaceutical compositions described herein: Remington: The Science and Practice of Pharmacy, Nineteenth Ed (Easton, Pa.: Mack Publishing Company, 1995); Hoover, John B., Remington's Pharmaceutical Sciences, Mack Publishing Co., Easton, Pa. 1975; Liberman, H. A. and Lachman, L., Eds., Pharmaceutical Dosage Forms, Marcel Decker, New York, N.Y., 1980; and Pharmaceutical Dosage Forms and Drug Delivery Systems, Seventh Ed. (Lippincott Williams & Wilkins 1999).

A pharmaceutical composition, as used herein, refers to a mixture of one or more of the compounds with other chemical components, such as carriers, stabilizers, diluents, dispersing agents, suspending agents, thickening agents, and/or excipients. In certain embodiments, the pharmaceutical composition facilitates administration of the compounds to an organism. In some embodiments, practicing the methods of treatment or use provided herein, therapeutically effective amounts cyclin-dependent kinase and/or DNA methyltransferase inhibitors provided herein are administered in a pharmaceutical composition to a mammal having a cancer, disease, disorder, or medical condition to be treated. In specific embodiments, the mammal is a human. In certain embodiments, therapeutically effective amounts vary depending on the severity of the cancer, disease, the age and relative health of the subject, the potency of the compound used, and other factors. The compounds are used in combination with each other or as components of mixtures.

In one embodiment, cyclin-dependent kinase inhibitor and/or DNA methyltransferase inhibitor components are formulated in an aqueous solution. In specific embodiments, the aqueous solution is selected from, by way of example only, a physiologically compatible buffer, such as Hank's solution, Ringer's solution, or physiological saline buffer. In other embodiments, cyclin-dependent kinase Inhibitors and/or DNA methyltransferase inhibitors are formulated for transmucosal administration. In specific embodiments, transmucosal formulations include penetrants that are appropriate to the barrier to be permeated. In still other embodiments wherein the compounds are formulated for other parenteral injections; appropriate formulations include aqueous or nonaqueous solutions. In specific embodiments, such solutions include physiologically compatible buffers and/or excipients.

In another embodiment, the compounds are formulated for oral administration. The compounds are formulated by combining the compounds with, e.g., pharmaceutically acceptable carriers or excipients. In various embodiments, the compounds are formulated in oral dosage forms that include, by way of example only, tablets, powders, pills, dragees, capsules, liquids, gels, syrups, elixirs, slurries, suspensions and the like.

In certain embodiments, pharmaceutical preparations for oral use are obtained by mixing one or more solid excipient with one or more of the compounds, optionally grinding the resulting mixture, and processing the mixture of granules, after adding suitable auxiliaries, if desired, to obtain tablets or dragee cores. Suitable excipients are, in particular, fillers such as sugars, including lactose, sucrose, mannitol, or sorbitol; cellulose preparations such as: for example, maize starch, wheat starch, rice starch, potato starch, gelatin, gum tragacanth, methylcellulose, microcrystalline cellulose, hydroxypropylmethylcellulose, sodium carboxymethylcellulose; or others such as: polyvinylpyrrolidone (PVP or povidone) or calcium phosphate. In specific embodiments, disintegrating agents are optionally added. Disintegrating agents include, by way of example only, cross-linked croscarmellose sodium, polyvinylpyrrolidone, agar, or alginic acid or a salt thereof such as sodium alginate.

In one embodiment, dosage forms, such as dragee cores and tablets, are provided with one or more suitable coating. In specific embodiments, concentrated sugar solutions are used for coating the dosage form. The sugar solutions optionally contain additional components, such as by way of example only, gum arabic, tale, polyvinylpyrrolidone, carbopol gel, polyethylene glycol, and/or titanium dioxide, lacquer solutions, and suitable organic solvents or solvent mixtures. Dyestuffs and/or pigments are also optionally added to the coatings for identification purposes. Additionally, the dyestuffs and/or pigments are optionally utilized to characterize different combinations of compound doses.

In certain embodiments, therapeutically effective amounts of the compounds are formulated into other oral dosage forms. Oral dosage forms include push-fit capsules made of gelatin, as well as soft, sealed capsules made of gelatin and a plasticizer, such as glycerol or sorbitol. In specific embodiments, push-fit capsules contain the active ingredients in admixture with one or more filler. Fillers include, by way of example only, lactose, binders such as starches, and/or lubricants such as tale or magnesium stearate and, optionally, stabilizers. In other embodiments, soft capsules contain one or more active compound that is dissolved or suspended in a suitable liquid. Suitable liquids include, by way of example only, one or more fatty oil, liquid paraffin, or liquid polyethylene glycol. In addition, stabilizers are optionally added.

In other embodiments, therapeutically effective amounts of the compounds are formulated for buccal or sublingual administration. Formulations suitable for buccal or sublingual administration include, by way of example only, tablets, lozenges, or gels. In still other embodiments, the compounds are formulated for parental injection, including formulations suitable for bolus injection or continuous infusion. In specific embodiments, formulations for injection are presented in unit dosage form (e.g., in ampoules) or in multi-dose containers. Preservatives are, optionally, added to the injection formulations. In still other embodiments, the pharmaceutical compositions are formulated in a form suitable for parenteral injection as sterile suspensions, solutions or emulsions in oily or aqueous vehicles. Parenteral injection formulations optionally contain formulatory agents such as suspending, stabilizing and/or dispersing agents. In specific embodiments, pharmaceutical formulations for parenteral administration include aqueous solutions of the active compounds in water-soluble form. In additional embodiments, suspensions of the compounds are prepared as appropriate oily injection suspensions. Suitable lipophilic solvents or vehicles for use in the pharmaceutical compositions described herein include, by way of example only, fatty oils such as sesame oil, or synthetic fatty acid esters, such as ethyl oleate or triglycerides, or liposomes. In certain specific embodiments, aqueous injection suspensions contain substances which increase the viscosity of the suspension, such as sodium carboxymethyl cellulose, sorbitol, or dextran. Optionally, the suspension contains suitable stabilizers or agents which increase the solubility of the compounds to allow for the preparation of highly concentrated solutions. Alternatively, in other embodiments, the active ingredient is in powder form for constitution with a suitable vehicle, e.g., sterile pyrogen-free water, before use.

In still other embodiments, therapeutically effective amounts of the compounds are administered topically. In some embodiments, the compounds are formulated into a variety of topically administrable compositions, such as solutions, suspensions, lotions, gels, pastes, medicated sticks, balms, creams or ointments. Such pharmaceutical compositions optionally contain solubilizers, stabilizers, tonicity enhancing agents, buffers and preservatives.

In yet other embodiments, therapeutically effective amounts of the compounds are formulated for transdermal administration. In specific embodiments, transdermal formulations employ transdermal delivery devices and transdermal delivery patches and can be lipophilic emulsions or buffered, aqueous solutions, dissolved and/or dispersed in a polymer or an adhesive. In various embodiments, such patches are constructed for continuous, pulsatile, or on demand delivery of pharmaceutical agents. In additional embodiments, the transdermal delivery of therapeutically effective amounts of the compounds is accomplished by means of iontophoretic patches and the like. In certain embodiments, transdermal patches provide controlled delivery of therapeutically effective amounts of compounds described herein. In specific embodiments, the rate of absorption is slowed by using rate-controlling membranes or by trapping the compound within a polymer matrix or gel. In alternative embodiments, absorption enhancers are used to increase absorption. Absorption enhancers or carriers include absorbable pharmaceutically acceptable solvents that assist passage through the skin. For example, in one embodiment, transdermal devices are in the form of a bandage comprising a backing member, a reservoir containing the compound optionally with carriers, optionally a rate controlling barrier to deliver the compound to the side of the host at a controlled and predetermined rate over a prolonged period of time, and means to secure the device to the skin.

In other embodiments, therapeutically effective amounts of the compounds are formulated for administration by inhalation. Various forms suitable for administration by inhalation include, but are not limited to, aerosols, mists or powders. Pharmaceutical compositions of therapeutically effective amounts of the compounds are conveniently delivered in the form of an aerosol spray presentation f-om pressurized packs or a nebulizer, with the use of a suitable propellant (e.g., dichlorodifluoromethane, trichlorofluoromethane, dichlorotetrafluoroethane, carbon dioxide or other suitable gas). In specific embodiments, the dosage unit of a pressurized aerosol is determined by providing a valve to deliver a metered amount. In certain embodiments, capsules and cartridges of, such as, by way of example only, gelatin for use in in inhaler or insufflator is formulated containing a powder mix of the compound and a suitable powder base such as lactose or starch.

In still other embodiments, therapeutically effective amounts of the compounds are formulated in rectal compositions such as enemas, rectal gels, rectal foams, rectal aerosols, suppositories, jelly suppositories, or retention enemas, containing conventional suppository bases such as cocoa butter or other glycerides, as well as synthetic polymers such as polyvinylpyrrolidone, PEG, and the like. In suppository forms of the compositions, a low-melting wax such as, but not limited to, a mixture of fatty acid glycerides, optionally in combination with cocoa butter is first malted.

In certain embodiments, pharmaceutical compositions are formulated in any conventional manner using one or more physiologically acceptable carriers comprising excipients and auxiliaries which facilitate processing of the compounds into preparations which can be used pharmaceutically. Proper formulation is dependent upon the route of administration chosen. Any pharmaceutically acceptable techniques, carriers, and excipients are optionally used as suitable. Pharmaceutical compositions comprising inhibitors targeting at least two super-enhancer components are manufactured in a conventional manner, such as, by way of example only, by means of conventional mixing, dissolving, granulating, dragee-making, levigating, emulsifying, encapsulating, entrapping or compression processes.

Pharmaceutical compositions include at least one pharmaceutically acceptable carrier, diluent or excipient and therapeutically effective amounts of one or more of the compounds as an active ingredient. The active ingredient is in free-acid or free-base form, or in a pharmaceutically acceptable salt form. In addition, the methods and pharmaceutical compositions described herein include the use of N-oxides, crystalline forms (also known as polymorphs), as well as active metabolites of these compounds having the same type of activity. All tautomers of the compounds are included within the scope of the compounds presented herein. Additionally, the compounds encompass unsolvated as well as solvated forms with pharmaceutically acceptable solvents such as water, ethanol, and the like. The solvated forms of therapeutically effective amounts of the compounds are also considered to be disclosed herein. In addition, the pharmaceutical compositions optionally include other medicinal or pharmaceutical agents, carriers, adjuvants, such as preserving, stabilizing, wetting or emulsifying agents, solution promoters, salts for regulating the osmotic pressure, buffers, and/or other therapeutically valuable substances.

Methods for the preparation of compositions comprising therapeutically effective amounts of the compounds include formulating the compounds with one or more inert, pharmaceutically acceptable excipients or carriers to form a solid, semi-solid or liquid. Solid compositions include, but are not limited to, powders, tablets, dispersible granules, capsules, cachets, and suppositories. Liquid compositions include solutions in which a compound is dissolved, emulsions comprising a compound, or a solution containing liposomes, micelles, or nanoparticles comprising a compound as disclosed herein. Semi-solid compositions include, but are not limited to, gels, suspensions and creams. The form of the pharmaceutical compositions described herein include liquid solutions or suspensions, solid forms suitable for solution or suspension in a liquid prior to use, or as emulsions. These compositions also optionally contain minor amounts of nontoxic, auxiliary substances, such as wetting or emulsifying agents, pH buffering agents, and so forth.

In some embodiments, pharmaceutical composition comprising therapeutically effective amounts of compounds described herein illustratively takes the form of a liquid where the agents are present in solution, in suspension or both. Typically when the composition is administered as a solution or suspension a first portion of the agent is present in solution and a second portion of the agent is present in particulate form, in suspension in a liquid matrix. In some embodiments, a liquid composition includes a gel formulation. In other embodiments, the liquid composition is aqueous.

In certain embodiments, useful aqueous suspensions contain one or more polymers as suspending agents. Useful polymers include water-soluble polymers such as cellulosic polymers, e.g., hydroxypropyl methylcellulose, and water-insoluble polymers such as cross-linked carboxyl-containing polymers. Certain pharmaceutical compositions described herein comprise a mucoadhesive polymer, selected for example from carboxymethylcellulose, carbomer (acrylic acid polymer), poly(methylmethacrylate), polyacrylamide, polycarbophil, acrylic acid/butyl acrylate copolymer, sodium alginate and dextran.

Useful pharmaceutical compositions also, optionally, include solubilizing agents to aid solubility of therapeutically effective amounts of compounds described herein. The term “solubilizing agent” generally Includes agents that result in formation of a micellar solution or a true solution of the agent. Certain acceptable nonionic surfactants, for example polysorbate 80, are useful as solubilizing agents, as can ophthalmically acceptable glycols, polyglycols, e.g., polyethylene glycol 400, and glycol ethers.

Furthermore, useful pharmaceutical compositions optionally include one or more pH adjusting agents or buffering agents, including acids such as acetic, boric, citric, lactic, phosphoric and hydrochloric acids; bases such as sodium hydroxide, sodium phosphate, sodium borate, sodium citrate, sodium acetate, sodium lactate and tris-hydroxymethylaminomethane; and buffers such as citrate/dextrose, sodium bicarbonate and ammonium chloride. Such acids, bases and buffers are included in an amount required to maintain pH of the composition in an acceptable range.

Other useful pharmaceutical compositions optionally include one or more preservatives to inhibit microbial activity. Suitable preservatives include mercury-containing substances such as merfen and thiomersal; stabilized chlorine dioxide; and quaternary ammonium compounds such as benzalkonium chloride, cetyltrimethylammonium bromide and cetylpyridinium chloride.

Still other useful compositions include one or more surfactants to enhance physical stability or for other purposes. Suitable nonionic surfactants include polyoxyethylene fatty acid glycerides and vegetable oils, e.g., polyoxyethylene (60) hydrogenated castor oil; and polyoxyethylene alkylethers and alkylphenyl others, e.g., octoxynol 10, octoxynol 40.

Still other useful compositions include one or more antioxidants to enhance chemical stability where required. Suitable antioxidants include, by way of example only, ascorbic acid and sodium metabisulfite.

In certain embodiments, aqueous suspension compositions are packaged in single-dose non-reclosable containers. Alternatively, multiple-dose reclosable containers are used, in which case it is typical to include a preservative in the composition.

In alternative embodiments, other delivery systems for hydrophobic pharmaceutical compounds are employed. Liposomes and emulsions are examples of delivery vehicles or carriers useful herein. In certain embodiments, organic solvents such as N-methylpyrrolidone are also employed. In additional embodiments, the compounds described herein are delivered using a sustained-release system, such as semipermeable matrices of solid hydrophobic polymers containing the therapeutic agent. Various sustained-release materials are useful herein. In some embodiments, sustained-release capsules release the compounds for a few weeks up to over 100 days. Depending on the chemical nature and the biological stability of the therapeutic reagent, additional strategies for protein stabilization are employed.

In certain embodiments, the formulations described herein comprise one or more antioxidants, metal chelating agents, thiol containing compounds and/or other general stabilizing agents. Examples of such stabilizing agents, include, but are not limited to: (a) about 0.5% to about 2% w/v glycerol, (b) about 0.1% to about 1% w/v methionine, (c) about 0.1% to about 2% w/v monothioglycerol, (d) about 1 mM to about 10 mM EDTA, (e) about 0.01% to about 2% w/v ascorbic acid, (f) 0.003% to about 0.02% w/v polysorbate 80, (g) 0.001% to about 0.05% w/v. polysorbate 20, (h) arginine, (i) heparin, (j) dextran sulfate, (k) cyclodextrins, (l) pentosan polysulfate and other heparinoids, (m) divalent cations such as magnesium and zinc; or (n) combinations thereof.

In some embodiments, the concentration of one or more of the compounds provided in the pharmaceutical compositions of the present invention is less than 100%, 90%, 80%, 70%, 60%, 50%, 40%, 30%, 20%, 19%, 18%, 17%, 16%, 15%, 14%, 13%, 12%, 11%, 10%, 9%, 8%, 7%, 6%, 5%, 4%, 3%, 2%, 1%, 0.5%, 0.4%, 0.3%, 0.2%, 0.1%, 0.09%, 0.08%, 0.07%, 0.06%, 0.05%, 0.04%, 0.03%, 0.02%, 0.01%, 0.009%, 0.008%, 0.007%, 0.006%, 0.005%, 0.004%, 0.003%, 0.002%, 0.001%, 0.0009%, 0.0008%, 0.0007%, 0.0006%, 0.0005%, 0.0004%, 0.0003%, 0.0002%, or 0.0001% w/w, w/v or v/v.

In some embodiments, the concentration of one or more of the compounds is greater than 90%, 80%, 70%, 60%, 50%, 40%, 30%, 20%, 19.75%, 19.50%, 19.25% 19%, 18.75%, 18.50%, 18.25% 18%, 17.75%, 17.50%, 17.25% 17%, 16.75%, 16.50%, 16.25% 16%, 15.75%, 15.50%, 15.25% 15%, 14.75%, 14.50%, 14.25% 14%, 13.75%, 13.50% 13.25% 13%, 12.75%, 12.50%, 12.25% 12%, 11.75%, 11.50%, 11.25% 11%, 10.75%, 10.50%, 10.25% 10%, 9.75%, 9.50%, 9.25% 9%, 8.75%, 8.50%, 8.25% 8%, 7.75%, 7.50%, 7.25% 7%, 6.75%, 6.50%, 6.25% 6%, 5.75%, 5.50%, 5.25% 5%, 4.75%, 4.50%, 4.25%, 4%, 3.75%, 3.50%, 3.25%, 3%, 2.75%, 2.50%, 2.25%, 2%, 1.75%, 1.50%, 125%, 1%, 0.5%, 0.4%, 0.3%, 0.2%, 0.1%, 0.09%, 0.08%, 0.07%, 0.06%, 0.05%, 0.04%, 0.03%, 0.02%, 0.01%, 0.009%, 0.008%, 0.007%, 0.006%, 0.005%, 0.004%, 0.003%, 0.002%, 0.001%, 0.0009%, 0.0008%, 0.0007%, 0.0006%, 0.0005%, 0.0004%, 0.0003%, 0.0002%, or 0.0001% w/w, w/v, or v/v.

In some embodiments, the concentration of the one or more compounds is in the range from approximately 0.0001% to approximately 50%, approximately 0.001% to approximately 40%, approximately 0.01% to approximately 30%, approximately 0.02% to approximately 29%, approximately 0.03% to approximately 28%, approximately 0.04% to approximately 27%, approximately 0.05% to approximately 26%, approximately 0.06% to approximately 25%, approximately 0.07% to approximately 24%, approximately 0.08% to approximately 23%, approximately 0.09% to approximately 22%, approximately 0.01% to approximately 21%, approximately 0.2% to approximately 20%, approximately 0.3% to approximately 19% approximately 0.4% to approximately 18%, approximately 0.5% to approximately 17%, approximately 0.6% to approximately 16%, approximately 0.7% to approximately 15%, approximately 0.8% to approximately 14%, approximately 0.9% to approximately 12%, approximately 1% to approximately 10% w/w, w/v or v/v.

In some embodiments, the concentration of one or more the one or more compounds is in the range from approximately 0.001% to approximately 10%, approximately 0.01% to approximately 5%, approximately 0.02% to approximately 4.5%, approximately 0.03% to approximately 4%, approximately 0.04% to approximately 3.5%, approximately 0.05% to approximately 3%, approximately 0.06% to approximately 2.5%, approximately 0.07% to approximately 2%, approximately 0.08% to approximately 1.5%, approximately 0.09% to approximately 1%, approximately 0.1% to approximately 0.9% w/w, w/v or v/v.

In some embodiments, the amount of the one or more compounds is equal to or less than 10 g, 9.5 g, 9.0 g, 8.5 g, 8.0 g, 7.5 g, 7.0 g, 6.5 g, 6.0 g, 5.5 g, 5.0 g, 4, 5 g, 4.0 g, 3.5 g, 3.0 g, 2.5 g, 2.0 g, 1.5 g, 1.0 g, 0.95 g, 0.9 g, 0.85 g, 0.8 g, 0.75 g, 0.7 g, 0.65 g, 0.6 g, 0.55 g, 0.5 g, 0.45 g, 0.4 g, 0.35 g, 0.3 g, 0.25 g, 0.2 g, 0.15 g, 0.1 g, 0.09 g, 0.08 g, 0.07 g, 0.06 g 0.05 g, 0.04 g, 0.03 g, 0.02 g, 0.01 g, 0.009 g, 0.008 g, 0.007 g, 0.006 g, 0.005 g 0.004 g, 0.003 g, 0.002 g 0.001 g 0.0009 g, 0.0008 g, 0.0007 g, 0.0006 g, 0.0005 g 0.0004 g, 0.0003 g, 0.0002 g, or 0.0001 g.

In some embodiments, the amount of the one or more compounds is more than 0.0001 g, 0.0002 g, 0.0003 g, 0.0004 g 0.0005 g 0.0006 g, 0.0007 g, 0.0008 g, 0.0009 g 0.001 g, 0.0015 g, 0.002 g, 0.0025 g, 0.003 g, 0.0035 g, 0.004 g 0.0045 g, 0.005 g, 0.0055 g, 0.006 g, 0.0065 g, 0.007 g 0.0075 g, 0.008 g, 0.0085 g 0.009 g, 0.0095 g, 0.01 g, 0.015 g, 0.02 g, 0.025 g, 0.03 g, 0.035 g, 0.04 g, 0.045 g, 0.05 g, 0.055 g, 0.06 g, 0.065 g, 0.07 g, 0.075 g, 0.08 g, 0.085 g, 0.09 g, 0.095 g, 0.1 g, 0.15 g, 0.2 g, 0.25 g, 0.3 g, 0.35 g, 0.4 g, 0.45 g, 0.5 g, 0.55 g, 0.6 g, 0.65 g, 0.7 g, 0.75 g, 0.8 g, 0.85 g, 0.9 g, 0.95 g, 1 g, 1.5 g, 2 g, 2.5, 3 g, 3.5, 4 g, 4.5 g, 5 g, 5.5 g, 6 g, 6.5 g, 7 g, 7.5 g, 8 g, 8.5 g, 9 g, 9.5 g, or 10 g.

In some embodiments, the amount of the one or more compounds is in the range of 0.0001-10 g, 0.0005-9 g, 0.001-8 g, 0.005-7 g, 0.01-6 g, 0.05-5 g, 0.1-4 g, 0.5-4 g, or 1-3 g.

EXAMPLES Example 1 Alvocidib Lowers MCL-1 Expression in a Time and Dose Independent Manner

An AML cell line, MV-4-11, expresses MCL-1. MCL-1 is a key anti-apoptotic protein in MV-4-11 cells. Alvocidib, a CDK9 inhibitor, lowers the expression of MCL-1, which is already well documented in the literature. Alvocidib down-regulates MCL-1 in a dose dependent manner (FIG. 1A). The dose dependence is observed by monitoring the relative expression of MCL-1 compared to β-actin when cells are dosed with alvocidib at concentrations of 0-8 μM. MV4-11 cells were treated with Alvocidib for 16 hrs in vitro. Following treatment, cells were harvested and prepared using standard western blotting technique for immuno-detection of MCL-1 and β-actin expression. Dosage of 0.1 μM Alvocidib reduced MCL-1 expression, whereas 1 μM Alvocidib completely blocked expression at 16 hrs.

In addition, alvocidib also down-regulates MCL-1 in a time-dependent manner (FIG. 1B). The time dependence is observed by monitoring the relative expression of MCL-1 compared to β-actin over time. The relative expression of MCL-1 was measured at 0.5-48 hour time points after dosing with 80 nM of alvocidib.

MV4-11 cells were treated with 80 nM Alvocidib in vitro for the times indicated. Following treatment, cells were harvested and prepared using standard western blotting technique for immunodetection of MCL-1 and β-actin expression. Alvocidib reduced MCL-1 expression as early as 1 hour post-treatment, whereas MCL-1 expression was nearly completely blocked at 16 hrs. This inhibition of expression was maintained for up to 48 hours following treatment. The relative expression of MCL-1 shows that alvocidib lowers the expression of MCL-1 in MV 4-11 cells.

Example 2 Combination Treatment with Alvocidib and Azacitidine and its Effect on Cell Viability

AML cell proliferation is inhibited synergistically by dosing with alvocidib and azacitidine. Alvocidib was used alone and in combination with azacitidine in order to determine the effect of the single drug and combination on cell viability. A significant shift in cell viability was observed when cells were dosed with the combination of alvocidib and azacitidine compared with cells dosed only with azacitidine.

MV 4-11 cells were dosed first with alvocidib (80 nM) or DMSO for 24 hours followed by a wash step. Following the wash step, the cells were dosed with azacitidine (30 μM to 0.001 μM) for an additional 72 hours. Measurement of cell viability was taken at 96 hours from the initial dose (72 hours after the wash step) and normalized to data collected for cells dosed with alvocidib only. Cell viability was then assessed in a Cell titer-glo assay, according to manufacturer protocol. Cell viability was then plotted against concentration on a logarithmic scale (FIG. 2). The addition of 80 nM Alvocidib results in a left shift of the IC50 curve, when normalized to the Alvocidib-only treatment, indicating synergistic activity in 5-Azacytidine efficacy with the combination. The resultant EC50 was lowered from 1.779 μM for cells dosed with only azacitidine compared to 0.6408 μM for cells also dosed with alvocidib.

These results provide evidence for increased activity (e.g., synergy) for a combination of alvocidib and azacitidine relative to the single agents.

Example 3 Combination Treatment Effect on Caspase 3/7 Activity and Apoptosis

Alvocidib was used combination with azacitidine to treat MV 4-11 cells. The combination treatment was compared with treatment using azacitidine only. The comparison was used to asses the synergistic effect of the combination on caspase 37 activity and apoptosis. The addition of 80 nM Alvocidib to 5-Azacytidine treatment results in synergistic increases in caspase activity in MV4-11 cells.

The cells were dosed initially with alvocidib for 24 hours followed by a wash step. Next, cells were dosed with azacitidine for 24 hours. Caspase 3/7 activity was measured 48 hours after the initial dose of alvocidib (24 hours after wash step and dose of azacitidine). The normalized caspase 3/7 activity of cells treated with the combination of alvocidib (FVP) and azacitidine was plotted against the concentration range of azacitidine (see FIG. 3). The dose of alvocidib remained constant (80 nM) across the dosing range for azacitidine (0.3 μM-30 μM). Apoptosis was then assessed in a Caspase-glo assay, according to manufacturer protocol.

In order to measure the synergistic effect of the combination of alvocidib and azacitidine, the caspase 3/7 activity for untreated cells was plotted with cells treated with a single agent and a combination of alvocidib and azacitidine. The cells treated with a single agent were treated with either alvocidib (80 nM) or azacitidine+DMSO (0.3 μM-30 μM) for 48 hours. The cells treated with a combination of alvocidib and azacitidine were initially treated with alvocidib (80 nM) for 24 hours. The cells were then washed and treated with azacitidine (0.3 μM-30 μM) for 24 hours. Results for different concentrations of azacitidine are provided in FIGS. 4A-4D. The comparisons show that at the tested concentrations of azacitidine and alvocidib the combination schedule gives rise to a synergistic increase in caspase 3/7 activity/apoptosis compared to untreated cells or cells treated with either agent alone.

Example 4 Combination Treatment with Alvocidib and Decitabine and its Effect on Cell Viability

FIGS. 5A and 5B present data from combination treatment of Alvocidib and decitabine in MV4-11 cells. MV4-11 cells were first treated for 96 hours with alvocidib+decitabine according to the general procedures of Example 2 at the concentrations indicated in FIG. 5A. A modest reduction in the IC50 (μM) was observed with the addition of alvocidib. Alternatively, MV4-11 cells were pre-treated for 24 hours with alvocidib, then treated for an additional 72 hours with decitabine (96 hours total, FIG. 5B). Here, a change of nearly 10-fold in the IC50 (μM) of decitabine with the addition of alvocidib (100 nM) was observed when alvocidib was administered prior to decitabine.

All of the U.S. patents, specifically U.S. Patent Application No. 62/200,499, U.S. patent application publications, U.S. patent applications, foreign patents, foreign patent applications and non-patent publications referred to in this specification are incorporated herein by reference, in their entirety to the extent not inconsistent with the present description.

From the foregoing it will be appreciated that, although specific embodiments of the invention have been described herein for purposes of illustration, various modifications may be made without deviating from the spirit and scope of the invention. Accordingly, the invention is not limited except as by the appended claims. 

1. A method for treating myelodysplastic syndrome (MDS) in a mammal in need thereof, the method comprising administering to the mammal a therapeutically effective amount of the following therapeutic agents: i) alvocidib, or a pharmaceutically acceptable salt thereof; and ii) a DNA methyltransferase inhibitor selected from azacitidine, or a pharmaceutically acceptable salt thereof, or decitabine, or a pharmaceutically acceptable salt thereof. 2-8. (canceled)
 9. The method of claim 1, wherein the alvocidib, or a pharmaceutically acceptable salt thereof, is administered to the mammal prior to administration of the DNA methyltransferase inhibitor.
 10. The method of claim 9, wherein the DNA methyltransferase inhibitor is administered within about 24 to 48 hours after administration of the alvocidib, or a pharmaceutically acceptable salt thereof.
 11. The method of claim 1, wherein the DNA methyltransferase inhibitor is administered to the mammal prior to administration of the alvocidib, or a pharmaceutically acceptable salt thereof. 12-15. (canceled)
 16. A kit comprising alvocidib, or a pharmaceutically acceptable salt thereof, a DNA methyltransferase inhibitor selected from azacitidine, or a pharmaceutically acceptable salt thereof, and decitabine, or a pharmaceutically acceptable salt thereof, and instructions for administering the alvocidib, or a pharmaceutically acceptable salt thereof, and the DNA methyltransferase inhibitor to a mammal in need of treatment for MDS. 17-19. (canceled)
 20. A pharmaceutical composition comprising a pharmaceutically acceptable carrier or excipient, alvocidib, or a pharmaceutically acceptable salt thereof, and a DNA methyltransferase inhibitor selected from azacitidine, or a pharmaceutically acceptable salt thereof, or decitabine, or a pharmaceutically acceptable salt thereof.
 21. The method of claim 1, wherein the DNA methyltransferase inhibitor is azacitidine, or a pharmaceutically acceptable salt thereof.
 22. The method of claim 1, wherein the DNA methyltransferase inhibitor is decitabine, or a pharmaceutically acceptable salt thereof.
 23. The method of claim 1, wherein the mammal is a human.
 24. The kit of claim 16, wherein the DNA methyltransferase inhibitor is azacitidine, or a pharmaceutically acceptable salt thereof.
 25. The kit of claim 16, wherein the DNA methyltransferase inhibitor is decitabine, or a pharmaceutically acceptable salt thereof.
 26. The kit of claim 16, wherein the mammal is a human.
 27. The pharmaceutical composition of claim 20, wherein the DNA methyltransferase inhibitor is azacitidine, or a pharmaceutically acceptable salt thereof.
 28. The pharmaceutical composition of claim 20, wherein the DNA methyltransferase inhibitor is decitabine, or a pharmaceutically acceptable salt thereof. 